JURY’S RETURN TO COURT

Taranaki Daily News, 25 November 1930, Page 7

JURY’S RETURN TO COURT

CLEMENCY SOUGHT BY COUNSEL. COMMENTS OF CHIEF JUSTICE. At 5.15 p.m. the foreman and two others of the jury re-entered the Court and asked- for a direction from the Chief Justice. The jury desired to know, said the foreman, whether the prisonei could be found guilty on one count only. His Honour said he could. . Ten-minutes later the jury returned with a- verdict of guilty on the fourth count as follows:—

That on August' 2 at New Plymouth he hastened the death of Lyall Gordon Christie and thereby committed manslaughter by omitting without lawful excuse to perform a legal duty assumed by him in respect of Christie in that in attending to and prescribing for him he failed to use reasonable care.

Asked whether , lie had anything to say before sentence was passed upon him/ Salanum remained impassive. Air. O’Leary spoke, “I ask your- Honour,” ha eaid, “to take into consideration these matters: First, the history of the child indicates that its prospects of life were not lengthy. That, I think, the jury has considered, in finding on the count it has. Secondly, the act that Salaman has been found guilty of has been an act of omission rather than of commission. Thirdly, the case was virtually forced on him as he was reluctant to take it. Fourthly, although this has no legal bearing on the question, Mrs. Christie and her family do not blame the prisoner for the outcome. I submit that the case is not a serious one "of its kind, Further, the accused has not bolstered up his case in any way in making his defence.” His Honour replied: “I shall take all those matters into consideration. Cf course I cannot lose sight of the fact that this is a plain case of charlatanism. Prisoner at the bar, I have no doubt you are a charlatan. “In giving judgment in a similar case in the’ Criminal ■ Court of Appeal in England the • learned Judge said that such quacks as the prisoner should ndt be allowed to go unpunished. With that opinion,” said the Chief Justice, “I cordially agree.” He thee sentenced - Salaman to imprisonment with hard labour for twelve'' calendar months. CROWN PROSECUTOR’S ADDRESS Before drawing attention to a resume of the case, said Mr. Weston, in hie address to the jury, he would remind them that the accused’s qualifications in no way entered into the cade because, first, there was no evidence on it and, secondly, the same law’ applied to everyone in New Zealand, whether registered medical practitioners or not.' Beyond the fact that "he could not sue for his fees and was not able to prefix the title of doctor to his name, the law made no distinction between Salaman and an ordinary medical man. The three points to be considered were:—,(l) Did the accused as the Christie’S medical adviser have conduct of the case? (2) Did his conduct of the case cause or accelerate the boy’s death? and (3) Did such conduct of the case show a lack of skill and knowledge or a want of care, or both? By lack of ridll and knowledge was meant the reasonable skill and knowledge that would be expected of a medical man who held himself out as able to deal with such cases. He would make this point before-pro-ceeding, said Mr. Weston; the evidence for the Crown stood uncontradicted. “Did the accused as the Christies’ medical adviser have conduct of the case? he asked. “It is clear that he gave the boy no medicine ,and charged nothing and that the ultimate decision to withdraw the insulin was made by the Christies and not by him. I suggest that is as much as can be said for him-” But Salaman had made it quite clear that unless the insulin was withdrawn he could not take the case. He wfent on to say that if it were withdrawn he thought he could cure the boy. It Wat clear that thjs was the accused’s practice in these cases. He would not touch the cases unless the insulin was withdrawn.' The Crown Prosecutor instanced the cases of the little girls Mackay and Robertson, and the letter from Salaman to the woman at Woodville. Taking the case as a whole there waa abundant evidence that that was hiS practice. The Christies, of course, had to make the decision to withdraw the insulin. Nobody could make that decision but the-Christie family. DID HE TAKE CHARGE OF CASE? Did he take charge of the case? He was, tlje Crown Prosecutor, the medical adviser in charge of the case. On hje suggestion they altered the diet and-withdrew the insulin until he ordered some more. Mrs. Christie accepted his advice as her medical adviser. All the accused’s suggestions were’implicitly carried out. On his advice she decided to stay with the boy at New Plymouth. She carried out all

his directions xyith regard. to putting the boy to bed, loosening his clothing and giving him drin'k. 'Salapian told the mother to let him know how the boy was getting on. That showed, he regarded himself as being in charge of the case. On the Saturday morning at. eight Mrs. -Christie went for * instructions. Salaman ordered half a dose, of insulin and it was given. At 10 o’clock she returned and Salaman gave instruction? to wait four hours before reporting, This was religiously carried out and the daughter returned at I‘2. He gave instructions about the injection in the arm and not the leg and ordered a quarter dose of insulin at two o’clock if there were no further change by then. ~ From Miss Christie’s evidence it appeared that Salaman regarded himielf as 'being in charge of-the case. Then, in the afternoon when the mother came again, she asked whether Salaman would come over or whether they should bring the boy to him. As far as Mrs. Christie was concerned she had complete confidence in 'him, Noone else was called in; Salaman had complete charge of the case. He reminded them of the peculiar conversation on the Friday when Mrs. Christie asked Salaman if he could give a death certificate.

Then there was the question, said Mr, Weston, whether Salaman’s treatment caused or accelerated death. They; had Mrs. Christie’s opinion, which was that the boy had been slipping back and would not live to a great age. That might be so. They must remem-/ ber that in those early days the doctors were not so well informed about insulin treatment. It was possible Dr.Crawford may have really believed the boy. could not .live after, the age of six, but if they were to believe the doctors in the .court, if the insulin had been continued the boy could have .carried on in quite good health. boy had a nourished body in good condition. He was at school the morning before he was brought to New Plymouth. There was nothing shown in the postmortem to cause death except diabetic toxaemia. They must consider too, continued Mr. Westdn, the case of Bernice Mackay. The insulin was withdrawn, she, went into a coma, was treated with insulin and was fully recovered to-day. VIEW OF THE TREATMENT. Still it was not necessary for them to hold that accused’s treatment caused the death entirely. It was sufficient that they say his treatment hastened the death of the boy. The effect of Salaman’s treatment was that withdrawing the insulin caused j the coma. When the coma came, instead of taking the proper emergency measures as the doctors had done with Bernice Mackay, he had done practically nothing. Insulin could be given only by the clumsy method of the hypodermic syringe. _As long as diabetic children had insulin they lived; when it was withdrawn they died. . . If Salaman had made a mistake he had a chance on Friday at mid-day of retrieving his mistake. There in his consulting room on Friday at midday was the little boy with sugar diabetes. He was asking for water and breathing heavily. Salaman was told, probably, that the insulin had been withdrawn, that the boy had been sick in the car and was complaining of pains. If the jurymen after hearing what they had of the case had seen that boy then they would have immediately said the boy was on the verge of diabetic cOma. Yet Salaman did nothing. Mackay had seen the danger in his oWn child and she had been saved at the hospital. Even on the Saturday morning it was not too late. ■ Knowing what Salaman did about the condition of the boy and getting the message on Saturday morning that ’the boy was lying On the: bed with his eyes half shut and not being able to swallow—would they themselves not have known at once that the boy was in a diabetic coma ? Even then Dr. Boyd said the boy had a fair chance of recovery with proper treatment. Dr. Church said he had a fifty-fifty chance. Did Salaman’s treatment show a lack of skill and knowledge or reasonable care? ‘ By care one meant a good deal —energy instead of laziness, interest instead of indifference. The Crown held that in all Salaman had shown a lamentable want of care. Accused held himself out as a medical man treating people for reward. Take the time when the Christies first called. They explained the trouble of the boy and then Salaman, instead of sitting down aqd goin* fully into the history of the cape Ind “taking a sample of the urine, the test for the disease, went through the play-acting of putting his stethoscope to the boy’s neck and said he had a kidney that was Aggravating the complaint. KNOCKING AWAY STILTS.” With that cursory examination Salaman advised the withdrawal of insujin, which, as Dr. Boyd put it, was knocking the stilts from under the boy’s feet. The insulin was withdrawn and the diet was not reduced as it should have been. Then he did another fatal thing; he sent fhe boy away till Saturday after withdrawing the insulin —sent him away from observation. “We return to the Friday,” eaid Mr. Weston. “If oncoming coma nad been shouted at him from a- megaphone it

could not have 'been plainer than it was from the symptoms of the boy in t'he consulting room. I should not like to say he knew it. It is obvious that he had not the skill and knowledge to reedguifeo it. The man showed no energy and interest in the cage. If he had put hji- mind to it he must have seen the trouble. "One of his remarks, almost suggests that he had an eye more for hU.ottn skin than the child. He had said it waslffcfey he had not the case or they would have blamed his treatment. All through the case, the Crown suggests; ajl that was required of 'Salaman was that he should hAve told Mrs. Christi© plainly to tik© the boy to a doctor.”

On Friday afternoon the boy was crying for drink and on Saturday morn■ing via? in a comi. There ,'tfib accused seemid to have' Scented danger because he returned to the insulin; though even then he did net go to see the child. On Saturday afteyqoon t|hey had the spectacle of tfye boy tahen from hi? death-bed and carried in blankets to Salamap. Again Salaman went through the with the stethosqope-r on a dying boy. “The only, glimpse of tlje accused ? mipd,” said Mr, Western, ‘<i? in his reinafks to Miss Arnpjtead and Detectjve 'iteappey. When Ml? s Arnii?tea-<i wept for him he said, ‘1 can’t go over, I’m ppt taking the To DfeteCtive Kearney he said,. ‘They byopght th? cpild here a week bbfoji it dl?4, hut I had nothing t© do with it.’ Does it ffot shoW tfet in hi? own mipd he kpew that his treatment was not what it should have beep, that he was upeasy about it in his conscience ? What did he do? He denied it.” OPENING OF THE DEFENCE. .“I will not apologise if I take ?pme time to address you, gentleman,”, said Mr. H. F. Otyeary, “becau? 6 & in tjie court the I represent, is to be rpost affected by this trial. You and I and ,His Hbfjour, too, will go away from tiii court to pursue; oiir Ordinary daily tisks; thi? case is but ah incident in our lives. But to Salaman it is of paramount- importDuring tpe hearing last week, said counsel, His Honour described the case as one of great public importance. It was not a matter between Mr?-. and Salaman, but was one between S©larriff.n and the Crown, representing the public. However, whatever their personal feelings might be about ipe interests of the public and the desirability of unregistered, men practising medicine; their duty was to satisfy themselves that the Crown had made out a case and proved it. “Whatever you may think, or Mr. Weston, or me, or His Honour, about' this case, it is a question for you, and you alone, to decide on the facts,” continued Mr. O’Leary. ’ -This man, he said, was a British subject, though he was not of the same race, colour, education or religion a? those in court. Counsel pointed out that Salaman was entitled to no greater.degree of justice than any other Brit- ' ish subject, but he asked the jurymen particularly to guard themselves against any racial prejudices. they might have. There were four counts in the charge, a serious one,. and he urged the jury to guard against compromising by finding Salaman guilty of hastening death instead of causing death. Counsel would submit tbit he Wai guilty of neither, .and he wanted the jury to be quite sure befbr.e it came to a decision to convict. SUGGESTION OF WEAKNESS. .Mr, O’Leary said he thought he was entitled to say that the way the indictment was drawn showed, the. Crown realised the weakness of its case.- In effect it said, “If he did not cause the death then he hastened the death of the boy, who was doomed to die.” “You know that that, is the invariable practice in the case of manslaughter charges here and in England,” said His Honour. ‘‘l was not aware of it, your Honour,” said counsel. - - . . “I am rather surprised to hear you say that,” replied the Chief Justice. “You must know that it is the custom' to provide the alternative counts.” Ih a case of violence qp a fatal motor accident there , was usually no dispute about who caused the death, continued counsel. “But that is not the here,” he went on. “The question here is whether Salaman caused or hastened the death of this boy. That is not admit-' ted. It i? definitely disputed and I ipvite you to consider that aspect of the case first.” ' Counsel pointed out that in 1526 the doctors at the Wanganui hospital said the boy was unlikely to live beyond two years, or at most till his sixth birthday. “Gentlemen, he lived actually eight, months after that,” said counsel. He pointed oijt, too, that oile of the doctors had told the mother the boy’s recovery w?s only temporary. Afterwards the mother had taken the matter rather into her oWn hands and changed the diet and. the boy seemed to get on well; one of the doctors congratulated her on hi© changed condition. Dr. Gunn had told the mother sho and the boy were living on the edge Of a precipice. What did that mean ? Surely that the boy was very near death. “And that’s the bby that Salaman is charged with killing,” sdid Mr. O’Leary. “Gentlemen, I submit you arc entitled to find that Salaman neither caused nor hastened his death.” . TREATMENT WITH INSULIN. Discussing -the question of insulin treatment, counsel said that in New Zealand, at any fate, there. wAs no ©tie who had been taking insulin longer than seven years. Was it time yet to say its effect was lasting ? Might it not be that its effect was gradually growing less in the body of this little boy? Might it not be that in some persons after seven years, in some after five years, in some after three years, insulin would begin to lose its effect? Could the medical men, in their present stage of- experience since the discovery of insulin in 1921, say definitely that that was not a possibility? None of these medical witnesses saw the child alive; their knowledge was gained at the post-mortem. Everybody was wise after the event. It was easy to say afterwards how they could have succeeded, in certain ci renin stances. Doctors after all were only human beings. These meh, counsel stressed, had no personal knowledge of the case. It had been said that ho child should die of diabetic coma to-day. Met the several doctors at Wapganui gave Mrs. Christie no hope that her boy would live long. Mr. O’Leary ventured the opinion that Dr. Robertson’s views on this subject differed widely from those expressed in the present case. Again, Lyall had been given insulin in the Wanganui - hospital, but for 22 months afterwards he was pot treated with it. “The stilts were knocked away without the dire results predicted by Dr. Boyd, the Wellington specialist,” commented counsel.

He had been given “holidays” of a day at a time from the treatment after that. A point made was that the doctor at Wanganui, who knew the case personally and well, stopped the insulin whep Lyall had a bad turn. That was directly opposed to the medical evidence in this casa-

DEATH CERTIFICATES PUT IN. The doctors had said they had not known of any diabetic child dying in coma when taking insulin, but the defence had put in the death certificates Of five diabetic boys under 14 who had succumbed in New Zealand during the past 18 months, at leAst three oi the deaths having apparently been caused by coma. He did not want to suggest carelessness or want of skill by the doctors and parents concerned, but he did suggest that these certificates proved that Dr. Boyd’s dogmatic statement that no child to-day should die of Coma was not warranted on the facts. When the mother—having noticed certain symptoms and that he was “slipping back”—took the boy to £r. Robertson, the doctor had not increased th? insulin. Why? Counsel suggested it was because the doctor knew the child was starting on the last stage of his journey to death. . Then what did this distracted woman do? Wishing to postpone the inevitable she took him away from the care of the recognised medical men, who could not cure him, and brought him to Salanian At New Plymouth. It waft submitted that before this she knew he was dobmed. “And. I.put it io you,, gentle; men,” declared counsel, “that there is an entire want of proof that Salaman hastened this boy’s death by so much as one hour.” CASE NOT SOLICITED. —■ • • Salsman, proceeded Mr. O’Leary, asked Ti th© boy had had insulin and was told he had. “Then I’ll not touch the c?se,” he had said. definitely. BA did not solicit the case or Accent money, Mr?. Christie had stopped the. insulin entirely of her own accord. Salaman left, it entirely with her to. decide. It mi»ht be said he should not have permitted tjie clfild to go off insulin, but if he did he was doing no more than Dr. Robertson hid dope., On the Friday Salaman had said it was just a? well he. .had not given any medicine; otherwise he might have been blamed. It. was clear the Christies did not act hastily in the matter; th?y held a family conference before coming to New Plymouth and again before stopping the insulin. Mrs. Christie and her daughter had acquired what might be called an expert knowledge of in?qli-n treatment and the effects of _ its withdirswl- They, it was submitted, had made the complete decision to stop the treatment; they were quite capable of acting! on their own acquired knowledge of what might happen. . Referring to the Saturday of the boy s death counsel said that apparently medical men had not quite, reached the stage where they could agree on how much insulin should be given under the circumstances. The, boy had been given a half dose and then a quarter dose. The local doctors had considered large doses of insulin were then necessary, but Dr. Boyd had said that while it w?s at one time thought large, doses were necessary in such -cases Joslin, an authority, advocated small and frequent doses. It seemed that doctors could not yet agree on how much insulin should be given in cases of diabetic emergency. The Crown had said Salaman had caused or hastened death by want of skill or care. To prove that the Crown must produce evidence making it beyond all reasonable doubt. “And I submit we have not had that evidence, commented Mr. O’Leary. “I say that in this case, as presented by the Crown evidence; there are not all the ingredients necessary to prove the offence beyond all. reasonable doubt, and I say . that Salaman is entitled to the benefit of that doubt.” Mr. O’Leary concluded by saying he would like to compliment the Crown Prosecutor on the fairness with which he had conducted his case, in the course of his duty. “Mr. Bennett and I have had our duty to perform,” counsel went on,' "and now His Honour is about to

perform his duty by summing up the case. And then will follow your duty. But to your duty is added the privilege of acquitting the prisoner,. and I. submit that you can, with justice and in accordance with the teipns of your oath, acquit the prisoner.” * " CHIEF JUSTICE’S ADDRESS. “In'the concluding portion of his able address,” said his Honour in opening his address to the jury, “Mr. O’Leary made an observation which I am bound to tell you was not correct arid which, I am satisfied, he did not mean. He said you have the privilege of returning a verdict of not guilty. That was erroneous. “If the Crown has not proved the case it is not your privilege, it is your duty, to find the accused not guilty. If, on the. other hand, you think ..the accused guilty, it is equally your duty to find him guilty without a moment’s hesitation. “It is the duty of the Crown to prove the charges without a doubt. If there is a reasonable doubt in your minds—-not a fanciful doubt—then it is your duty to acquit the prisoner. My duty is to explain to you the law of the case and yours is to apply it. I may express ari opinion of the facts. If I do, do not think I am trying to force them down your throats. You will merely give them the consideration you think they ' warrant. “First let me explain the legal, position. No question of intention is involved. If there is the intention to cause death that is murder. If death is brought about by a culpable act or an omission of a legal duty, but without intent, that is manslaughter.” They had had read to them two sections of the statute. First, the Act prescribed the legal duty involved in a case of - that kind. It stated that everyone who undertook to administer surgical or inedicril treatment Was bound to use reasonable skill arid care. Further, it stated that everyone who by an act of omission or lack of reasonable skill and care caused or hastened the death of a person was criminally responsible. CASE IN ENGLISH COURT. That law had been applied in England in 11)16, said his Honour, in a case before the Court of Criminal Appeal. The appellant was a violinist who had become interested in herbalism as a treatment for himself and others for rheumatism. He treated a woman who, under his orders, gave up food for a certain time and died. During crossexamination the doctor admitted she might have died from heart disease at any time. The appellant was found guilty. The judge said that she wbuld probably not have lived long, but that the treatment given had hastened the woman’s death. No person, he held, had the right to shorten the life of another eVeh. if only by an hour. There was the law they had to apply. On questions of fact they were not bound by any expression of his opinion, but on questions of law they were bound by whQ.t he told them the law was. If they found that the accused, by not having and not using reasonable knowledge, care arid skill either brought about the death of the boy or shortened his life, he was guilty of manslaughter. Something had been said to them about the variations of the indietjnent, continued his Honour. Mr. O’Leary, in the course of his advocacy, had suggested that it pointed to weakness in the Crown case. That was not so. It was the correct way of stating an indictment under the circumstances and was done in both England and New Zealand. The accused chose to advise. It was for them to say whether he was adminis-

tering medical treatment. If he were they had to find whether he used reasonable skill and care. If they found that he had not, then they had to find whether the boy’s death was caused or his life shortened by that want of skill and care. There was a slight difference between the accused and a medical man. The judge in England had said that a medical man by reason of passing certain examinations was presumed to have a certain knowledge. He might have the knowledge and not apply it, and in that case he was responsible. “What were the facts in this case? The accused made no examination of the boy, he took no sample of the urine. He applied a stethoscope to the boy’s neck, if you please, gentlemen, and then added that he was suffering from kidney trouble. On that you might reasonably find that the accused had lack o r reasonable skill. That does not- necessarily mean that the accused was guilty on the charge, but it was very reprehensible. He might as well have put the stethoscope to the crown of the boy’s hat or the sole of his boot.” Evidence had been called from Mackay and Robertson. The jury could not find the accused guilty on that evidence, but the evidence was admissible (1) to rebut any possible defence; (2) to show system in stopping the insulin; (3) to tend to show that what the medical evidence said —that when insulin treatment was applied io a child in diabetic coina she recovered —was correct. ' The medical evidence showed that in a case of diabetic coma resulting from the withdrawal of insulin, recovery would follow the resumption of the insulin treatment. Again, said his Honour, it was his duty to say that, whether a person accused of a charge of that kind be a medical man or not a mere mistake of judgment that any medical practitioner might make would not necessarily jus-, tify a jury in finding him guilty. But a careless, negligent and ignorant mistake was a very different thing. Mr. O’Leary had said three of the, death certificates he had put in were those of children who had died in diabetic coma. They wdre entitled, to give them consideration, but they must remember that they had no evidence of the full circumstances under which those" children had died. It was held that no treatment was given. That the jury had to decide. It was held that no medicine was given. That was true. It was said that no fee was charged. That was true, but it did not matter. If, however, they were satisfied that the accused had undertaken the treatment of the boy the facts that no medicine was given and no fee was charged were immaterial. QUESTION' OF TREATMENT. It had been said that the insulin treat--ment had been withdrawn by the Christies. That did not matter. If they came to the conclusion that it was advised by the accused, if they accepted the evidence of Mrs. Christie and her son that the accused had said he would, could or might cure the boy if insulin was stopped, that was reasonable ground .for assuming treatment. But if they did come to the conclusion that he had begun the treatment and had not used skill and care they still had to come tp the conclusion that the boy’s death was caused by that lack of knowledge, skill and care. The accused had seen the boy on Friday twice. If they accepted the medical evidence the signs were there that diabetic coma was imminent. They could test the matter by the accused’s conduct. Did he treat the boy on that day? Did he not tell them to give him insulin, to take him home and give him packs, and so on ? If they were satisfied he 'was treating the boy on Friday and that the boy’s condition on that day was such that it was obvious that the boy was on the verge of diabetic coma, what was the accused’s duty? He .knew the boy had been taking insulin. A competent person, according to the doctors, ■would have pumped insulin into the boy. What did the accused do? He said: “Insulin is a drug; give him half a dose of insulin.” He said he wanted to get the insulin out of the boy’s system before beginning his treatment. Then, the jury had to consider would the boy’s life have been saved or lengthened by the insulin treatment? If they found that was so they had all the elements for the case. It was a fact that some doctors had advised Mrs. Christie that the boy would die before he was six. Of course, said his Honour, there was a danger that he might die at any £ime. At the same time the boy had a right to be. given treatment which would prolong his life. His Honour then re-read parts of the evidence to refresh the jury’s mind, reviewing the conversation between Salaman and Mrs. Christie on Tuesday. Salaman had said, “If you keep the boy off the insulin for a few days—-the longer the better- —I will undertake tlje treatment.” If on the Friday a medical man had called he would have said, “Apply insulin.” What Salaman said was to take him home and give him hot packs and so on. Was that treating him? ELEMENTS NEEDED FOR GUILT. Mrs. Christie had said she would not have stopped the insulin if she had’not gone to Salaman. If they considered the continuance of the insulin would have kept the boy alive and she had stopped it on Salaman’s advice, then they had all the elements to find him guilty on the charge. They had the. evidence of Dr. Boyd, who had pointed out that insulin was the recognised treatment for diabetes. They must not assume that any lower standard must be set by "a jury in the case of a non-medical practitioner than in the case of the medical practitioner. That would never do; it would be offering a premium to the non-medical man. Even on the Friday afternoon when, according to the doctor’s evidence, insulin should have been pumped into the boy, the accused was still saying to Miss Christie that he wanted to get the insulin out of the boy’s system. Salaman had told the boy’s brother that the crisis would arrive. Apparently he knew that. What he did not know, according to the case for the Crown, was that the proper treatment in the crisis was insulin.

Then on the Saturday when Miss Armistead came over and said the boy was dying he_ said, “Dying, eh?” and that he had not been treating the case. That was for the jury to say. Then there was the evidence of Dr. Church, a general medical practitioner, who said it was almost certain that insulin treatment would have saved the boy. It was a difficult thing to be absolutely certain about anything. It was even difficult for a jury when it brought in a verdict of guilty to be absolutely certain. Of course, if there was a reasonable doubt that was a different matter.

The first question the jury had to decide was, did Salaman undertake the treatment of a child? If they found that he did not they must acquit him. The .next question was did he use reasonable skill and care and knowledge? On that point they had the evidence of the doctors that on Friday any reasonable medical man would have known coma was imminent. It would have seemed that Salaman hardly knew. If he did know, then when the coma came he ought to have known the child would die. If they decided that he had not used reasonable care and skill they had next- to decide whether he hastened or accelerated the boy’s death. If they had any reasonable doubt about any of those questions, said his Honour, they must bring in. a verdict of

not guilty. If, on the other hand, they believed that he had treated the boy and by his treatment, due to lack, of reasonable knowledge and care, or to not using skill and care if he had it, so listened the boy’s death, it was their duty to bring in a verdict of guilty.